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Abstract
Background Severe malaria remains a leading cause of death worldwide. A greater understanding of its impact on multiple organ systems is essential in reducing the burden of disease. In this review we will summarize previously reported cardiovascular parameters of both adults and children with severe malaria. Method For this systematic review we searched MEDLINE and PUBMED for all papers published on cardiac function in severe malaria from January 1, 1990 until September 1, 2019. Severe malaria was defined as per World Health Organization. Publications were included if there was data from echocardiography, Pulse Contour Cardiac Output (PiCCO), or Pulmonary Arterial catheters (PAC) reported. Studies were excluded if related to medication induced cardiac dysfunction, malaria in pregnancy, or included subjects with known pre-existing heart disease. Results Twenty-four studies met inclusion criteria, the majority of which were studies of adult patients or a mixed cohort. Six solely involved pediatric patients. Significant heterogeneity existed in the cardiac parameters measured and results reported. One pediatric and one adult study suggested a reduced preload state during severe malaria. Cardiac systolic function was reported primarily within, or above, normative numeric ranges established in uninfected pediatric patients without anemia. Extensive variability existed in adult studies with reports of an elevated cardiac index in two studies, normal cardiac function in two studies, and descriptions of decreased function in two studies. Two reports suggest afterload in pediatric severe malaria is reduced. Reports of changes in the systemic vascular resistance of adults with severe malaria are inconsistent, with two trials demonstrating an increase and two suggesting a decrease. Studies demonstrated a mild rise in pulmonary pressure in both pediatric and adult patients that normalized by discharge. Conclusion Based on limited data, the cardiovascular effects of severe malaria appear to be heterogeneous and vary depending on age. Further detailed studies are required to explore and understand the overall hemodynamic effects of this high burden disease.
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Ishioka H, Plewes K, Pattnaik R, Kingston HWF, Leopold SJ, Herdman MT, Mahanta K, Mohanty A, Dey C, Alam S, Srinamon K, Mohanty A, Maude RJ, White NJ, Day NPJ, Hossain MA, Faiz MA, Charunwatthana P, Mohanty S, Ghose A, Dondorp AM. Associations Between Restrictive Fluid Management and Renal Function and Tissue Perfusion in Adults With Severe Falciparum Malaria: A Prospective Observational Study. J Infect Dis 2020; 221:285-292. [PMID: 31504666 PMCID: PMC6935998 DOI: 10.1093/infdis/jiz449] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 08/30/2019] [Indexed: 12/26/2022] Open
Abstract
Background Liberal fluid resuscitation has proved harmful in adults with severe malaria, but the level of restriction has not been defined. Methods In a prospective observational study in adults with severe falciparum malaria, restrictive fluid management was provided at the discretion of the treating physician. The relationships between the volume of fluid and changes in renal function or tissue perfusion were evaluated. Results A total of 154 patients were studied, 41 (26.6%) of whom died. Median total fluid intake during the first 6 and 24 hours from enrollment was 3.3 (interquartile range [IQR], 1.8–5.1) mL/kg per hour and 2.2 (IQR, 1.6–3.2) mL/kg per hour, respectively. Total fluid intake at 6 hours was not correlated with changes in plasma creatinine at 24 hours (n = 116; rs = 0.16; P = .089) or lactate at 6 hours (n = 94; rs = −0.05; P = .660). Development of hypotensive shock or pulmonary edema within 24 hours after enrollment were not related to the volume of fluid administration. Conclusions Restrictive fluid management did not worsen kidney function and tissue perfusion in adult patients with severe falciparum malaria. We suggest crystalloid administration of 2–3 mL/kg per hour during the first 24 hours without bolus therapy, unless the patient is hypotensive.
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Affiliation(s)
- Haruhiko Ishioka
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Department of Anesthesiology and Critical Care, Jichi Medical University, Saitama Medical Center, Saitama, Japan
| | - Katherine Plewes
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | | | - Hugh W F Kingston
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Stije J Leopold
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - M Trent Herdman
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | | | | | - Chandan Dey
- Ispat General Hospital, Rourkela, Orissa, India
| | - Shamsul Alam
- Chittagong Medical College and Hospital, Chittagong, Bangladesh
| | - Ketsanee Srinamon
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Akshaya Mohanty
- Infectious Disease Biology Unit, Research Unit of Institute of Life Sciences, Ispat General Hospital, Rourkela, Orissa, India.,Institute of Life Sciences, Department of Biotechnology, Government of India, Bhubaneswar, Orissa, India
| | - Richard J Maude
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom.,Harvard TH Chan School of Public Health, Harvard University, Boston, Massachusetts, USA
| | - Nicholas J White
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Nicholas P J Day
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Md Amir Hossain
- Chittagong Medical College and Hospital, Chittagong, Bangladesh
| | | | - Prakaykaew Charunwatthana
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | | | - Aniruddha Ghose
- Chittagong Medical College and Hospital, Chittagong, Bangladesh
| | - Arjen M Dondorp
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
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3
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Kingston HWF, Ghose A, Rungpradubvong V, Satitthummanid S, Herdman MT, Plewes K, Ishioka H, Leopold SJ, Sinha I, Intharabut B, Piera K, McNeil Y, Mohanty S, Maude RJ, White NJ, Day NPJ, Yeo TW, Hossain MA, Anstey NM, Dondorp AM. Cell-Free Hemoglobin Is Associated With Increased Vascular Resistance and Reduced Peripheral Perfusion in Severe Malaria. J Infect Dis 2020; 221:127-137. [PMID: 31693729 DOI: 10.1093/infdis/jiz359] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 09/25/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND In severe falciparum malaria, unlike sepsis, hypotension on admission is uncommon. We hypothesized that low nitric oxide bioavailability due to the presence of cell-free hemoglobin (CFH) increases vascular tone in severe malaria. METHODS Patients with severe malaria (n = 119), uncomplicated malaria (n = 91), or suspected bacterial sepsis (n = 56), as well as healthy participants (n = 50), were recruited. The systemic vascular resistance index (SVRI) was estimated from the echocardiographic cardiac index and the mean arterial pressure. RESULTS SVRI and hematocrit levels were lower and plasma CFH and asymmetric dimethylarginine levels were higher in patients with malaria, compared with healthy participants. In multivariate linear regression models for mean arterial pressure or SVRI in patients with severe malaria, hematocrit and CFH but not asymmetric dimethylarginine were significant predictors. The SVRI was lower in patients with suspected bacterial sepsis than in those with severe malaria, after adjustment for hematocrit and age. Plasma CFH levels correlated positively with the core-peripheral temperature gradient and plasma lactate levels and inversely with the perfusion index. Impaired peripheral perfusion, as reflected by a low perfusion index or a high core-peripheral temperature gradient, predicted mortality in patients with severe malaria. CONCLUSIONS CFH is associated with mean arterial pressure, SVRI, and peripheral perfusion in patients with severe malaria. This may be mediated through the nitric oxide scavenging potency of CFH, increasing basal vascular tone and impairing tissue perfusion.
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Affiliation(s)
- Hugh W F Kingston
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia.,Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
| | | | - Voravut Rungpradubvong
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Chulalongkorn University.,Cardiac Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Sudarat Satitthummanid
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Chulalongkorn University.,Cardiac Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - M Trent Herdman
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University
| | - Katherine Plewes
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Haruhiko Ishioka
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University
| | - Stije J Leopold
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Ipsita Sinha
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Benjamas Intharabut
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University
| | - Kim Piera
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - Yvette McNeil
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | | | - Richard J Maude
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Nicholas J White
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Nicholas P J Day
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Tsin W Yeo
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore.,Communicable Disease Centre, Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, Singapore
| | | | - Nicholas M Anstey
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - Arjen M Dondorp
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
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4
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Plewes K, Leopold SJ, Kingston HWF, Dondorp AM. Malaria: What's New in the Management of Malaria? Infect Dis Clin North Am 2019; 33:39-60. [PMID: 30712767 DOI: 10.1016/j.idc.2018.10.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The global burden of malaria remains high, with 216 million cases causing 445,000 deaths in 2016 despite first-line treatment with artemisinin-based combination therapy. Decreasing transmission in Africa shifts the risk for severe malaria to older age groups as premunition wanes. Prompt diagnosis and treatment with intravenous artesunate in addition to appropriate supportive management are critical to reduce deaths from severe malaria. Effective individual management is challenging in settings with limited resources for higher-level care. Adjunctive therapies targeting the underlying pathophysiological pathways have the potential to reduce mortality. Resistance to artemisinin derivatives and their partner drugs threaten malaria management and control.
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Affiliation(s)
- Katherine Plewes
- Malaria Department, Mahidol Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, 3/F 60th, Anniversary Chalermprakiat Building, 420/6 Rajvithi Road, Bangkok 10400, Thailand; Department of Medicine, University of British Columbia, Vancouver General Hospital, 452D Heather Pavilion East, 2733 Heather Street, Vancouver, British Columbia V5Z 3J5, Canada
| | - Stije J Leopold
- Malaria Department, Mahidol Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, 3/F 60th, Anniversary Chalermprakiat Building, 420/6 Rajvithi Road, Bangkok 10400, Thailand
| | - Hugh W F Kingston
- Nuffield Department of Clinical Medicine, University of Oxford, Old Road Campus, Headington, Oxford OX3 7BN, UK; Malaria Department, Mahidol Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, 3/F 60th, Anniversary Chalermprakiat Building, 420/6 Rajvithi Road, Bangkok 10400, Thailand
| | - Arjen M Dondorp
- Nuffield Department of Clinical Medicine, University of Oxford, Old Road Campus, Headington, Oxford OX3 7BN, UK; Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, 3/F 60th, Anniversary Chalermprakiat Building, 420/6 Rajvithi Road, Bangkok 10400, Thailand.
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5
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Bruneel F, Raffetin A, Corne P, Llitjos JF, Mourvillier B, Argaud L, Wolff M, Laurent V, Jauréguiberry S. Management of severe imported malaria in adults. Med Mal Infect 2018; 50:213-225. [PMID: 30266432 DOI: 10.1016/j.medmal.2018.08.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 08/30/2018] [Indexed: 11/28/2022]
Abstract
Severe malaria accounts for approximately 10% of all cases of imported malaria in France; cases are mainly due to Plasmodium falciparum, while other Plasmodium species are possible but uncommon (P. vivax, P. knowlesi, P. malariae, and P. ovale). On the basis of WHO criteria for endemic areas, the French criteria defining severe imported malaria in adults have been progressively adapted to the European healthcare level. Management of severe imported malaria is a diagnostic and treatment emergency and must be initially conducted in the intensive care unit. Anti-infective treatment is now based on intravenous artesunate, which must be available in every hospital of the country likely to receive severe imported malaria patients. Intravenous quinine is thus used as a second-line treatment and is restricted to limited indications. Critical care management of organ failure is essential, particularly in patients presenting with very severe malaria. To date, no adjunctive therapy (including exchange transfusion) has demonstrated clear beneficial effects.
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Affiliation(s)
- F Bruneel
- Réanimation médico-chirurgicale, hôpital Mignot, centre hospitalier de Versailles, 177, rue de Versailles, 78150 Le Chesnay, France.
| | - A Raffetin
- Médecine interne, maladies infectieuses et tropicales, CHI Villeneuve-Saint-Georges, 94190 Villeneuve-Saint-Georges, France
| | - P Corne
- Réanimation médicale, CHU de Montpellier, 34000 Montpellier, France
| | - J F Llitjos
- Réanimation médicale, CHU Cochin, 75014 Paris, France
| | - B Mourvillier
- Réanimation médicale et infectieuse, CHU Bichat-Claude-Bernard, 75018 Paris, France
| | - L Argaud
- Réanimation médicale, CHU Edouard-Herriot, 69000 Lyon, France
| | - M Wolff
- Réanimation médicale et infectieuse, CHU Bichat-Claude-Bernard, 75018 Paris, France
| | - V Laurent
- Réanimation médico-chirurgicale, hôpital Mignot, centre hospitalier de Versailles, 177, rue de Versailles, 78150 Le Chesnay, France
| | - S Jauréguiberry
- Maladies infectieuses et tropicales, CHU Pitié-Salpêtrière, 75013 Paris, France
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6
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Aung NM, Nyein PP, Htut TY, Htet ZW, Kyi TT, Anstey NM, Kyi MM, Hanson J. Antibiotic Therapy in Adults with Malaria (ANTHEM): High Rate of Clinically Significant Bacteremia in Hospitalized Adults Diagnosed with Falciparum Malaria. Am J Trop Med Hyg 2018; 99:688-696. [PMID: 30014826 DOI: 10.4269/ajtmh.18-0378] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
It has been believed that concomitant bacteremia is uncommon in adults hospitalized with falciparum malaria. Accordingly, the World Health Organization treatment guidelines presently only recommended additional antibacterial therapy in these patients if they have a clinical syndrome compatible with serious bacterial infection. Admission blood cultures were collected from 20 consecutive adults in Myanmar, hospitalized with a positive immunochromatographic test and blood film, suggesting a diagnosis of falciparum malaria; four (20%) had bacteremia with a clinically significant pathogen. These case series' data were pooled with a previously published multicenter study from Myanmar which had also collected blood cultures in adults hospitalized with a diagnosis of falciparum malaria. Among 87 patients in the two studies, 13 (15%) had clinically significant bacteremia on admission, with Gram-negative organisms in 10 (77%) and Staphylococcus aureus in the remaining three (23%). Bacteremic patients had more severe disease than non-bacteremic patients (median [interquartile range] respiratory coma acidosis malaria score 2 [1-4] versus 1 [1-2], P = 0.02) and were more likely to die (2/13 [15%] versus 1/74 [1%], P = 0.01). However, bacterial coinfection was suspected clinically in a minority of bacteremic patients (5/13 [38%] compared with 13/70 [19%] of non-bacteremic patients, P = 0.11). Concomitant bacteremia in adults diagnosed with falciparum malaria may be more common than previously believed and is difficult to identify clinically in resource-poor settings. Death is more common in these patients, suggesting that clinicians should have a lower threshold for commencing empirical antibacterial therapy in adults diagnosed with falciparum malaria in these locations than is presently recommended.
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Affiliation(s)
- Ne Myo Aung
- University of Medicine 2, Yangon, Myanmar.,Insein General Hospital, Yangon, Myanmar
| | | | | | | | - Tint Tint Kyi
- Department of Medical Care, Ministry of Health and Sports, Nay Pyi Taw, Myanmar
| | - Nicholas M Anstey
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - Mar Mar Kyi
- University of Medicine 2, Yangon, Myanmar.,Insein General Hospital, Yangon, Myanmar
| | - Josh Hanson
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia.,Kirby Institute, University of New South Wales, Sydney, Australia.,University of Medicine 2, Yangon, Myanmar
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7
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Plewes K, Turner GD, Dondorp AM. Pathophysiology, clinical presentation, and treatment of coma and acute kidney injury complicating falciparum malaria. Curr Opin Infect Dis 2018; 31:69-77. [PMID: 29206655 PMCID: PMC5768231 DOI: 10.1097/qco.0000000000000419] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW Cerebral impairment and acute kidney injury (AKI) are independent predictors of mortality in both adults and children with severe falciparum malaria. In this review, we present recent advances in understanding the pathophysiology, clinical features, and management of these complications of severe malaria, and discuss future areas of research. RECENT FINDINGS Cerebral malaria and AKI are serious and well recognized complications of severe malaria. Common pathophysiological pathways include impaired microcirculation, due to sequestration of parasitized erythrocytes, systemic inflammatory responses, and endothelial activation. Recent MRI studies show significant brain swelling in both adults and children with evidence of posterior reversible encephalopathy syndrome-like syndrome although targeted interventions including mannitol and dexamethasone are not beneficial. Recent work shows association of cell-free hemoglobin oxidation stress involved in the pathophysiology of AKI in both adults and children. Paracetamol protected renal function likely by inhibiting cell-free-mediated oxidative stress. It is unclear if heme-mediated endothelial activation or oxidative stress is involved in cerebral malaria. SUMMARY The direct causes of cerebral and kidney dysfunction remain incompletely understood. Optimal treatment involves prompt diagnosis and effective antimalarial treatment with artesunate. Renal replacement therapy reduces mortality in AKI but delayed diagnosis is an issue.
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Affiliation(s)
- Katherine Plewes
- Faculty of Tropical Medicine, Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Division of Infectious Diseases, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Gareth D.H. Turner
- Department of Cellular Pathology, John Radcliffe Hospital
- Nuffield Department of Clinical Medicine, Center for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Arjen M. Dondorp
- Faculty of Tropical Medicine, Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Nuffield Department of Clinical Medicine, Center for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
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8
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Dondorp AM, Hoang MNT, Mer M. Recommendations for the management of severe malaria and severe dengue in resource-limited settings. Intensive Care Med 2017; 43:1683-1685. [PMID: 27816986 PMCID: PMC5633627 DOI: 10.1007/s00134-016-4602-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Accepted: 10/19/2016] [Indexed: 10/26/2022]
Affiliation(s)
- Arjen M. Dondorp
- Mahidol-Oxford Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400 Thailand
- Oxford Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Mai Nguyen Thi Hoang
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Mervyn Mer
- Department of Critical Care, Johannesburg Hospital and University of the Witwatersrand, Johannesburg, South Africa
| | - for the Sepsis in Resource-Limited Settings-Expert Consensus Recommendations Group of the European Society of Intensive Care Medicine (ESICM) and the Mahidol-Oxford Research Unit (MORU) in Bangkok, Thailand
- Mahidol-Oxford Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400 Thailand
- Oxford Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
- Department of Critical Care, Johannesburg Hospital and University of the Witwatersrand, Johannesburg, South Africa
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9
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Soltanifar D, Carvalho B, Sultan P. Perioperative considerations of the patient with malaria. Can J Anaesth 2014; 62:304-18. [PMID: 25471683 PMCID: PMC7102007 DOI: 10.1007/s12630-014-0286-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 11/25/2014] [Indexed: 11/28/2022] Open
Abstract
Purpose Malaria is a life-threatening infectious disease caused by the Plasmodium parasite. Increased global travel has resulted in an escalation in the number of imported cases seen in developed countries. Patients with malaria may present for surgery in both endemic and non-endemic countries. This article reviews the perioperative considerations when managing patients with malaria. Source A literature review of anesthesia, perioperative care, and malaria-related articles was performed using the MEDLINE®, EMBASE™, and Web of Science databases to identify relevant articles published in English during 1945-2014. Of the 303 articles matching the search criteria, 265 were excluded based on title and abstract. Eleven of the remaining 38 articles were relevant to anesthesia/perioperative care, and 27 articles were identified as having direct relevance to critical care medicine. Principal findings The majority of imported malaria cases are caused by the falciparum species, which is associated with the greatest degree of morbidity and mortality. Various organ systems may be impacted as a consequence of changes in the structure and function of parasitized erythrocytes. Preoperative assessment should focus on establishing the species of malaria, the severity of disease, assessing the degree of end-organ impairment, and initiating treatment of malaria prior to surgery. Intravenous artesunate is the treatment of choice for severe falciparum malaria. Quinine is a second-line agent but has a narrow therapeutic index and particularly hazardous side effects. Intraoperatively, attention should focus on fluid management, dynamics of cerebral blood flow, and avoidance of hypoglycemia. Postoperative care of severe cases should ideally take place in a critical care unit as there may be ongoing requirements for multi-organ support, including renal replacement therapy, ventilation, and/or inotropic support. The safety of neuraxial anesthesia has not been well studied in the setting of malaria. Conclusions Malaria remains one of the most devastating infectious diseases worldwide. Multiple organ systems can be impacted as a consequence of changes in structure and function of parasitized erythrocytes. Safe perioperative management requires a sound knowledge of all these potential system effects.
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10
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Hanson J, Anstey NM, Bihari D, White NJ, Day NP, Dondorp AM. The fluid management of adults with severe malaria. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:642. [PMID: 25629462 PMCID: PMC4318383 DOI: 10.1186/s13054-014-0642-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Fluid resuscitation has long been considered a key intervention in the treatment of adults with severe falciparum malaria. Profound hypovolemia is common in these patients and has the potential to exacerbate the acidosis and acute kidney injury that are independent predictors of death. However, new microvascular imaging techniques have shown that disease severity correlates more strongly with obstruction of the microcirculation by parasitized erythrocytes - a process termed sequestration. Fluid loading has little effect on sequestration and increases the risk of complications, particularly pulmonary edema, a condition that can develop suddenly and unpredictably and that is frequently fatal in this population. Accordingly, even if a patient is clinically hypovolemic, if there is an adequate blood pressure and urine output, there may be little advantage in infusing intravenous fluid beyond a maintenance rate of 1 to 2 mL/kg per hour. The optimal agent for fluid resuscitation remains uncertain; significant anemia requires blood transfusion, but colloid solutions may be associated with harm and should be avoided. The preferred crystalloid is unclear, although the use of balanced solutions requires investigation. There are fewer data to guide the fluid management of severe vivax and knowlesi malaria, although a similar conservative strategy would appear prudent.
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11
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Marks M, Gupta-Wright A, Doherty JF, Singer M, Walker D. Managing malaria in the intensive care unit. Br J Anaesth 2014; 113:910-21. [PMID: 24946778 PMCID: PMC4235570 DOI: 10.1093/bja/aeu157] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The number of people travelling to malaria-endemic countries continues to increase, and malaria remains the commonest cause of serious imported infection in non-endemic areas. Severe malaria, mostly caused by Plasmodium falciparum, often requires intensive care unit (ICU) admission and can be complicated by cerebral malaria, respiratory distress, acute kidney injury, bleeding complications, and co-infection. The mortality from imported malaria remains significant. This article reviews the manifestations, complications and principles of management of severe malaria as relevant to critical care clinicians, incorporating recent studies of anti-malarial and adjunctive treatment. Effective management of severe malaria includes prompt diagnosis and early institution of effective anti-malarial therapy, recognition of complications, and appropriate supportive management in an ICU. All cases should be discussed with a specialist unit and transfer of the patient considered.
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Affiliation(s)
- M Marks
- The Hospital for Tropical Diseases, Mortimer Market Centre, Capper Street, London, UK Department of Clinical Research, Faculty of Infectious and Tropical Diseases London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
| | - A Gupta-Wright
- The Hospital for Tropical Diseases, Mortimer Market Centre, Capper Street, London, UK Department of Clinical Research, Faculty of Infectious and Tropical Diseases London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
| | - J F Doherty
- The Hospital for Tropical Diseases, Mortimer Market Centre, Capper Street, London, UK
| | - M Singer
- Department of Critical Care, University College London Hospital NHS Foundation Trust, 3rd Floor, 235 Euston Road, London NW1 2BU, UK
| | - D Walker
- Department of Critical Care, University College London Hospital NHS Foundation Trust, 3rd Floor, 235 Euston Road, London NW1 2BU, UK
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Hanson J, Lam SWK, Alam S, Pattnaik R, Mahanta KC, Uddin Hasan M, Mohanty S, Mishra S, Cohen S, Day N, White N, Dondorp A. The reliability of the physical examination to guide fluid therapy in adults with severe falciparum malaria: an observational study. Malar J 2013; 12:348. [PMID: 24079262 PMCID: PMC3851438 DOI: 10.1186/1475-2875-12-348] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Accepted: 09/20/2013] [Indexed: 12/29/2022] Open
Abstract
Background Adults with severe malaria frequently require intravenous fluid therapy to restore their circulating volume. However, fluid must be delivered judiciously as both under- and over-hydration increase the risk of complications and, potentially, death. As most patients will be cared for in a resource-poor setting, management guidelines necessarily recommend that physical examination should guide fluid resuscitation. However, the reliability of this strategy is uncertain. Methods To determine the ability of physical examination to identify hypovolaemia, volume responsiveness, and pulmonary oedema, clinical signs and invasive measures of volume status were collected independently during an observational study of 28 adults with severe malaria. Results The physical examination defined volume status poorly. Jugular venous pressure (JVP) did not correlate with intravascular volume as determined by global end diastolic volume index (GEDVI; rs = 0.07, p = 0.19), neither did dry mucous membranes (p = 0.85), or dry axillae (p = 0.09). GEDVI was actually higher in patients with decreased tissue turgor (p < 0.001). Poor capillary return correlated with GEDVI, but was present infrequently (7% of observations) and, therefore, insensitive. Mean arterial pressure (MAP) correlated with GEDVI (rs = 0.16, p = 0.002), but even before resuscitation patients with a low GEDVI had a preserved MAP. Anuria on admission was unrelated to GEDVI and although liberal fluid resuscitation led to a median hourly urine output of 100 ml in 19 patients who were not anuric on admission, four (21%) developed clinical pulmonary oedema subsequently. MAP was unrelated to volume responsiveness (p = 0.71), while a low JVP, dry mucous membranes, dry axillae, increased tissue turgor, prolonged capillary refill, and tachycardia all had a positive predictive value for volume responsiveness of ≤50%. Extravascular lung water ≥11 ml/kg indicating pulmonary oedema was present on 99 of the 353 times that it was assessed during the study, but was identified on less than half these occasions by tachypnoea, chest auscultation, or an elevated JVP. A clear chest on auscultation and a respiratory rate <30 breaths/minute could exclude pulmonary oedema on 82% and 72% of occasions respectively. Conclusions Findings on physical examination correlate poorly with true volume status in adults with severe malaria and must be used with caution to guide fluid therapy. Trial registration Clinicaltrials.gov identifier: NCT00692627
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Affiliation(s)
- Josh Hanson
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
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13
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Management of severe malaria: enthusiasm for fluid resuscitation dampened by lung water. Crit Care Med 2013; 41:1139-40. [PMID: 23528760 DOI: 10.1097/ccm.0b013e318283cab1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Fluid resuscitation of adults with severe falciparum malaria: effects on Acid-base status, renal function, and extravascular lung water. Crit Care Med 2013; 41:972-81. [PMID: 23324951 DOI: 10.1097/ccm.0b013e31827466d2] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of liberal fluid resuscitation of adults with severe malaria. DESIGN, SETTING, PATIENTS, AND METHODS: Twenty-eight Bangladeshi and Indian adults with severe falciparum malaria received crystalloid resuscitation guided by transpulmonary thermodilution (PiCCO) in an intensive care setting. Systemic hemodynamics, microvascular indices and measures of acidosis, renal function, and pulmonary edema were followed prospectively. RESULTS All patients were hypovolemic (global end-diastolic volume index<680 mL/m) on enrollment. Patients received a median (range) 3230 mL (390-7300) of isotonic saline in the first 6 hours and 5450 mL (710-13,720) in the first 24 hours. With resuscitation, acid-base status deteriorated in 19 of 28 (68%), and there was no significant improvement in renal function. Extravascular lung water increased in 17 of 22 liberally resuscitated patients (77%); eight of these patients developed pulmonary edema, five of whom died. All other patients survived. All patients with pulmonary edema during the study were hypovolemic or euvolemic at the time pulmonary edema developed. Plasma lactate was lower in hypovolemic patients before (rs=0.38; p=0.05) and after (rs=0.49; p=0.01) resuscitation but was the strongest predictor of mortality before (chi-square=9.9; p=0.002) and after resuscitation (chi-square=11.1; p<0.001) and correlated with the degree of visualized microvascular sequestration of parasitized erythrocytes at both time points (rs=0.55; p=0.003 and rs=0.43; p=0.03, respectively). Persisting sequestration was evident in 7 of 15 patients (47%) 48 hours after enrollment. CONCLUSIONS Lactic acidosis--the strongest prognostic indicator in adults with severe falciparum malaria--results from sequestration of parasitized erythrocytes in the microcirculation, not from hypovolemia. Liberal fluid resuscitation has little effect on this sequestration and does not improve acid-base status or renal function. Pulmonary edema--secondary to increased pulmonary vascular permeability--is common, unpredictable, and exacerbated by fluid loading. Liberal fluid replacement of adults with severe malaria should be avoided.
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15
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Askling HH, Bruneel F, Burchard G, Castelli F, Chiodini PL, Grobusch MP, Lopez-Vélez R, Paul M, Petersen E, Popescu C, Ramharter M, Schlagenhauf P. Management of imported malaria in Europe. Malar J 2012; 11:328. [PMID: 22985344 PMCID: PMC3489857 DOI: 10.1186/1475-2875-11-328] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Accepted: 08/19/2012] [Indexed: 11/10/2022] Open
Abstract
In this position paper, the European Society for Clinical Microbiology and Infectious Diseases, Study Group on Clinical Parasitology, summarizes main issues regarding the management of imported malaria cases. Malaria is a rare diagnosis in Europe, but it is a medical emergency. A travel history is the key to suspecting malaria and is mandatory in patients with fever. There are no specific clinical signs or symptoms of malaria although fever is seen in almost all non-immune patients. Migrants from malaria endemic areas may have few symptoms.Malaria diagnostics should be performed immediately on suspicion of malaria and the gold- standard is microscopy of Giemsa-stained thick and thin blood films. A Rapid Diagnostic Test (RDT) may be used as an initial screening tool, but does not replace urgent microscopy which should be done in parallel. Delays in microscopy, however, should not lead to delayed initiation of appropriate treatment. Patients diagnosed with malaria should usually be hospitalized. If outpatient management is preferred, as is the practice in some European centres, patients must usually be followed closely (at least daily) until clinical and parasitological cure. Treatment of uncomplicated Plasmodium falciparum malaria is either with oral artemisinin combination therapy (ACT) or with the combination atovaquone/proguanil. Two forms of ACT are available in Europe: artemether/lumefantrine and dihydroartemisinin/piperaquine. ACT is also effective against Plasmodium vivax, Plasmodium ovale, Plasmodium malariae and Plasmodium knowlesi, but these species can be treated with chloroquine. Treatment of persistent liver forms in P. vivax and P. ovale with primaquine is indicated after excluding glucose 6 phosphate dehydrogenase deficiency. There are modified schedules and drug options for the treatment of malaria in special patient groups, such as children and pregnant women. The potential for drug interactions and the role of food in the absorption of anti-malarials are important considerations in the choice of treatment.Complicated malaria is treated with intravenous artesunate resulting in a much more rapid decrease in parasite density compared to quinine. Patients treated with intravenous artesunate should be closely monitored for haemolysis for four weeks after treatment. There is a concern in some countries about the lack of artesunate produced according to Good Manufacturing Practice (GMP).
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Affiliation(s)
- Helena H Askling
- Department of Medicine Solna/Unit for Infectious Diseases, Karolinska Institutet, Stockholm, Sweden
- Department of Communicable Disease Control and Prevention, Stockholm County Council, Stockholm, Sweden
| | - Fabrice Bruneel
- Intensive Care Unit, Centre Hospitalier de Versailles, Site André Mignot, 177 rue de Versailles, Le Chesnay 78150, France
| | - Gerd Burchard
- Bernhard-Nocht-Institut für Tropenmedizin, Hamburg, Germany
| | - Francesco Castelli
- University Division of Infectious and Tropical Diseases, University of Brescia and Spedali Civili General Hospital, Brescia, Italy
| | - Peter L Chiodini
- Hospital for Tropical Diseases and London School of Hygiene and Tropical Medicine, London, UK
| | - Martin P Grobusch
- Center for Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Rogelio Lopez-Vélez
- Tropical Medicine & Clinical Parasitology. Infectious Diseases Department.Hospital Ramón y Cajal, Madrid, Spain
| | - Margaret Paul
- Department and Clinic of Tropical and Parasitic Diseases, University of Medical Sciences, Poznan, Poland
| | - Eskild Petersen
- Department of Infectious Diseases, Aarhus University Hospital Skejby, Aarhus, Denmark
| | - Corneliu Popescu
- Clinical Hospital of Infectious and Tropical Diseases "Dr.Victor Babes", University of Medicine and Pharmacy "Carol Davila" Bucharest, Bucharest, Romania
| | - Michael Ramharter
- Department. of Medicine I, Div. of Infectious Diseases and Tropical Medicine, Medical University of Vienna, Vienna, Austria
| | - Patricia Schlagenhauf
- University of Zürich, Centre for Travel Medicine, Division of Epidemiology and Communicable Diseases, Zürich, Switzerland
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Abstract
Malaria remains the most important parasitic infection in humans. There have been significant advances in the treatment of both nonsevere and severe malaria with the advent of artemisinin combination therapies and parenteral artesunate, but the optimum supportive management of severe malaria is unclear. A broadly acceptable therapy for the prevention of relapses in Plasmodium vivax infection has not been discovered. Globally, the priority remains to prevent infection in the vulnerable, to move toward elimination where feasible, and to ensure that effective treatment is available to all. In developed settings, prevention of infection and its early recognition are crucial.
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Affiliation(s)
- Behzad Nadjm
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, UK.
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